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  • br The follow up clinic These trial

    2019-05-21


    The follow-up clinic These trial results have significant implications for clinic efficiencies. The safe and effective replacement of the bulk of “routine” in-clinic evaluations demonstrated in TRUST (Fig. 3) has a huge implication for resource utilization. Although demanding adjustment to different workflow patterns (and mindsets), especially for alert notifications, this is more than balanced by the great reduction of routine non-actionable in-person evaluations. This was amply demonstrated by Ricci et al. using HM [17,20]. Prior to implementation of this innovative technology, all involved personnel, including patients, were primed to process and expectations. The results were astonishing: the median committed monthly manpower was 55.5min health personnel per 100 patients with a range of CIEDs. This was based on a cooperative interaction between a reference nurse and a responsible physician with an agreed list of respective tasks and responsibilities. Although demanding extra resources, nurse-based remote patient management improves follow-up quality, generates manpower efficiencies and directs only problematic remote assessments (which occur infrequently) to physicians otherwise released to their other assignments. The HomeGuide results highlighted the key role of a trained dedicated allied professional, especially important for maintaining early reaction ability. However, resources to operate such a virtual clinic may not be universally available. Other options, to be fully developed, include industry-supported units (e.g. in Asia-Pacific [21]) or third party service providers directing information from all proprietary technologies to a single readily accessible (Web-based) platform. Patient engagement is important to successful remote management and acceptance and satisfaction of HM has been high [22]. Communication, initially education regarding its function to enhance overall clinical management (and not an emergency system), should be continued since caffeic acid phenethyl ester disease is a dynamic condition and needs (medications, programming, in-person evaluations) change with time. This is obviously essential when retrieved data drive treatment e.g. physician-directed patient self-management based on direct hemodynamic measurements [23]. It is important to note that HM does not supplant the first post-implant in-person evaluation [3] important for assessment of wound healing, determination of chronic thresholds and setting of final pacing parameters. Problems such as lead perforations or failures requiring revision and symptomatic reactions to implantation (e.g. pacemaker syndrome, diaphragmatic pacing and pocket infection) cluster in this early post-implant. They occur more frequently with dual-chamber or resynchronization units [24–26].
    Device management Remote monitoring with capability for same day discovery of problems (even when asymptomatic), when appropriate technology and clinic infrastructure are in place [27], may profoundly affect patient management. The most obvious application of remote monitoring is for detection of system dysfunction [12,28]. Although safety concerns underpinned original post-implant follow-up schedules e.g. for assessing pacing thresholds, integrity of components and charging capacitors, these issues now belong to a different era. Current generation devices require no such maintenance, have extreme reliability, and perform an array of autoregulatory functions. Nevertheless, early detection of system perturbations, especially for components subject to advisories, remains an imperative. This underlies the original announcements from professional societies for “device manufacturers use wireless and remote monitoring technologies to identify device malfunctions in a timely manner and to increase the accuracy of detecting and reporting device malfunctions”, carrying the expectation of early detection and correction of device malfunction [29,30]. TRUST confirmed that conventional monitoring methods underreport device related problems (Fig. 4) [12]. Automatic remote monitoring, in contrast, enhanced the discovery of system problems (even when asymptomatic) and enabled prompt clinical decisions regarding conservative versus surgical management. Most ICD system malfunctions could be identified within 24h of occurrence even though performance problems were often asymptomatic [27]. [In contrast, these would remain quiescent with conventional follow-up or even wanded remote systems (Fig. 1)]. Reprogramming changes accounted for the majority of “actionable” interrogations in the TRUST trial [11]. This is important since programming may directly affects mortality [31]. Results of ECOST secondary analyses have high clinical value [15]. Clinical reactions enabled by early detection resulted in a large reduction in the number of actually delivered shocks (−72%), the number of charged shocks (−76%), the rate of inappropriate shocks (−52%) and at the same time exerting a favorable impact on battery longevity. Reduced generator replacements, aside from cost issues, avoid the considerable morbidity associated with this surgery. Avoiding inappropriate shocks is one of the most challenging aspects of ICD management. Although the merits of correct programming of ICD detection parameters are crucial to the occurrence of inappropriate therapies, the ECOST study brought the novel observation that automatic remote home monitoring is also an instrument to decrease the incidence of inappropriate therapy.